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IL <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. Hazeltof- <br /> Aveti, Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> !!APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. <br /> A ..-THIS: PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date- Issued <br /> Application F plica {P W, t/.E, A�-�S= c?� � (Complete In Triplicate) zS3 3�ffl <br /> tion is herere by rriade to the San Joaquin'Local Health District. for :a permit to construct <br /> and/or install the work' herein described. This,application is made in compliance with San Joaquin <br /> I. County Ordinance No. 1862 and the .R les and -Regulati ns of the San Joaquin Local Health District,. <br /> Wz T� <br /> JOB ADDRESS/LOCATION <br /> ` CENSUS TRACT <br /> Owner's Name <br /> * - PhoneWA 9—j <br /> Address . `:'y ; r-, -a.. a�,,' <br /> City <br /> Contractor's Name A <br /> License # D�Phone - O <br /> rTYPE OF WORK (Check) c,ZNEW WELL / DEEPEN _ <br /> � /—/' 'RECONDITION RECONDITION_/ / DESTRUCTIONw <br /> PUMP INSTALLATION / / PUMP REPAIR PUMP REPiLACEMENT,. ,f ;/ <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES --- PIT_,PRIVY. <br /> SEWAGE DISPOSAL FIELD CESSPOOL/,SEEPAGE PIT _ # OTHER1� <br /> �1 <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL } Ex <br /> CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia: of Well cavation f , <br /> Domestic/private Drilled Dia. of Well Casing Af <br /> i <br /> Domestic/public Driven <br /> Ii' Gauge of Casing <br /> Irrigation , <br /> Gravel Pack /Depth of Grout Seal i �F <br /> Cathodic ProtectiolnY <br /> Rotary Type of <br /> Disposal 0 Other � `` Other ti nformation <br /> Geophysical <br /> Surf-ace-Seal' Installed B <br /> PUMP 19STALLATION: Contractor <br /> Type of pump# 'x_ t '- 1�1 <br /> H.P. dl <br /> PUMP REPLACEMENT: /:t/ State�'Work Done <br /> PUMP .RE,PAIR ` '• Y sL <br /> .State Work Done {�i <br /> -Jfk � <br /> DESTRUCTION OF WELL: Well Diameter i <br /> Approximate Depth <br /> XsDe.scribe Ma-terial and Procedure <br /> J <br /> I hereby agree to compiy with all laws and regulations of the San Joaquin .Local Health.-District <br /> and the State of,California pertainingvto,or regulating well -construction.,� 'Within..`FIFTEEN DAYS <br /> after completion of 'm,y 'work on a new well, I will furnish the San.-Jbaquin Local-Health District a <br /> WELL DRILLERS REPORT of the well and natify"�them before putting'the''well infuse.. The above <br /> information is true to th'e best of my knowledge and belief'. T WILL CALL -FOR At GROUT INSPECTION p <br /> PRIOR TO CROqJTING .AND FI INSPECTION.. . � ; <br /> SIGNED �., ' ?�' <br /> TITLE <br /> RAW PLOT PLAN O EVERSE"SIDE) <br /> PHASE I <br /> .. ,� _e-FOR DEPART NT USE ONLY <br /> � <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: a DATE7 �/ <br /> PHASE II CROAT INSPECTION <br /> INSPECTION B PHASE III FINAL INSPECTIO - <br /> DATE7`?�, INSPECTION BY /29 <br /> TE <br /> E H 1426 <br /> Rev. • 1-7.4 j� n�7.7 _ 2M <br />